Social Differentials in the Outcomes of Depression : A Longitudinal Register Study

Depression is a leading cause of disability worldwide. At worst, it may lead to frequent hospitalisation and even premature death. The risk of suicide is particularly high among the depressed. This study assessed whether social and economic resources protect depressed patients from psychiatric hospital admission and premature mortality. The study also aimed to establish the role of alcohol and the rapidly increased antidepressant treatment of depression in these outcomes. The study used large, longitudinal register samples of the Finnish adult population, combining information from various administrative registers. Depression was assessed from psychiatric hospital care and antidepressant purchases. Treatment and depression outcomes were assessed in 1-10-year follow-ups. The results indicate that at least in a population already in contact with the healthcare system, antidepressant treatment and depression outcomes vary only modestly according to social factors. However, material aspects of socioeconomic position such as a low income, not owning a home and being unemployed increased the risk of hospital admission for depression by 20-40 per cent among those with previous depression treatment, even after controlling for baseline depression severity and psychiatric comorbidity, whereas education and occupational social class were unrelated to admission risk. Having no partner and living without co-resident children also increased the admission risk. None of the social factors studied buffered against excess mortality among the depressed. Educational differences in the prevalence of antidepressant use before and after hospital care for depression were small and mostly limited to the period after discharge. Antidepressant use immediately after discharge was slightly less common among those with a low level of education, but educational differences increased thereafter as antidepressant use decreased more rapidly among this group. Differences in daily antidepressant use that met treatment guidelines were more pronounced than those for any antidepressant use, suggesting a need for improving treatment adequacy and adherence particularly among patients with a low level of education. The study established the central role of excessive alcohol consumption as a pathway to depression mortality. Alcohol-related causes accounted for about half of the excess mortality of depressed men and around a third of depressed women. Improving the detection and management of substance use problems would thus be critical for reducing depression mortality. Increased antidepressant sales do not seem to have prevented female suicides. However, among men an increase in the proportion of antidepressant users receiving minimally adequate treatment reduced non-alcohol-related suicides. The results suggest that increased adequacy of antidepressant treatment has been more central in reducing suicide rates than the mere increase in per-capita antidepressant sales or prevalence of antidepressant use.Masennus on yleinen mielenterveyden häiriö, joka vakavimmillaan vaatii sairaalahoitoa ja voi johtaa jopa ennenaikaiseen kuolemaan. Erityisesti itsemurhan riski on masentuneilla suuri. Tämän tutkimuksen tavoitteena oli selvittää, suojaavatko sosiaaliset ja taloudelliset resurssit, kuten korkea koulutus, korkeat tulot, työssäolo tai perhe, masennuspotilaita psykiatriseen sairaalahoitoon päätymiseltä ja ennenaikaiselta kuolemalta. Lisäksi tarkasteltiin, millainen merkitys yhtäältä alkoholinkäytöllä ja toisaalta nopeasti yleistyneellä masennuslääkkeiden käytöllä on masennuksen ennusteelle. Tutkimuksessa käytettiin laajoja rekisteriaineistoja, joissa masennus pääteltiin psykiatrisen sairaalahoidon ja masennuslääkkeiden käytön perusteella. Masentuneiden lääkkeiden käyttöä ja ennustetta tarkasteltiin 1-10 vuoden seurannassa. Tutkimuksen perusteella väestöryhmien väliset erot masennuslääkehoidossa sekä masennuksen ennusteessa ovat vähäisiä ainakin jo masennuksen vuoksi hoidon piirissä olevilla. Puolison kanssa asuminen sekä materiaaliset resurssit, kuten korkeat tulot, omistusasuminen ja työssä olo kuitenkin suojasivat masennuspotilaita masennuksen vuoksi sairaalaan päätymiseltä. Sen sijaan korkea koulutus tai korkea ammattiasema eivät suojanneet sairaalahoitoon päätymiseltä. Mitkään tutkituista sosiaalisista ja taloudellisista resursseista eivät suojanneet masennuspotilaita ennenaikaiselta kuolemalta. Koulutusryhmien väliset erot masennuslääkkeiden käytössä ennen masennukseen saatua sairaalahoitoa ja sen jälkeen olivat pieniä ja rajoittuivat sairaalahoidon jälkeiseen aikaan. Lääkekäyttö oli hieman vähäisempää matalasti koulutetuilla heti sairaalajakson jälkeen, mutta erot kasvoivat seurannan aikana, sillä matalasti koulutetut lopettivat lääkekäytön nopeammin. Koulutusryhmien väliset erot korostuivat päivittäisessä, hoitosuositusten mukaisessa lääkekäytössä. Tulosten perusteella olisi syytä kiinnittää huomiota etenkin matalasti koulutettujen masennuspotilaiden hoidon riittävyyteen ja jatkuvuuteen. Tutkimus osoitti, että alkoholinkäyttö on keskeinen syy masennuspotilaiden korkeaan kuolleisuuteen: miehillä masennuspotilaiden korkeammasta kuolleisuudesta noin puolet ja naisilla noin kolmannes johtui alkoholista. Päihdeongelmien havaitseminen ja hoito ovatkin tutkimuksen perusteella keskeisessä roolissa masennuspotilaiden kuolleisuuden ehkäisyssä. Masennuslääkkeiden käytön yleistyminen ei näytä ehkäisseen naisten itsemurhia. Miehillä hoidon keston vähimmäiskriteerit täyttävän masennuslääkehoidon yleistyminen näyttäisi kuitenkin ehkäisseen sellaisia itsemurhia, joissa uhrin alkoholipäihtymys ei ollut myötävaikuttavana tekijänä. Tulosten perusteella masennuslääkehoidon yleistyminen sinänsä ei näyttäisi ehkäisseen itsemurhia, vaan keskeistä on ollut kestoltaan riittävän hoidon yleistyminen

Are some populations resilient to recessions? : Economic fluctuations and mortality during a period of economic decline and recovery in Finland

Peer reviewe

Current Unemployment, Unemployment History, and Mental Health : A Fixed-Effects Model Approach

Poor mental health among the unemployed-the long-term unemployed in particular-is established, but these associations may be driven by confounding from unobserved, time-invariant characteristics such as past experiences and personality. Using longitudinal register data on 2,720,431 residents aged 30-60 years, we assessed how current unemployment and unemployment history predict visits to specialized care due to psychiatric conditions and self-harm in Finland in 2008-2018. We used linear ordinary-least-squares and fixed-effects models. Prior to adjusting for time-invariant characteristics, current unemployment was associated with poor mental health, and the risk increased with longer unemployment histories. Accounting for all time-invariant characteristics with the fixed-effects models, these associations attenuated by approximately 70%, yet current unemployment was still associated with a 0.51 (95% confidence interval: 0.48, 0.53) percentage-point increase in the probability of poor mental health among men and women. Longer unemployment histories increased the probability among men in their 30s but not among older men or among women. The results indicate that selection by stable characteristics may explain a major part of the worse mental health among the unemployed and especially the long-term unemployed. However, even when controlling for this selection, current unemployment remains associated with mental health.Peer reviewe

Avoliitot ikääntyneillä : Yleistyminen, sosioekonomiset taustatekijät ja purkautumistavat

Only abstract. Paper copies of master’s theses are listed in the Helka database (http://www.helsinki.fi/helka). Electronic copies of master’s theses are either available as open access or only on thesis terminals in the Helsinki University Library.Vain tiivistelmä. Sidottujen gradujen saatavuuden voit tarkistaa Helka-tietokannasta (http://www.helsinki.fi/helka). Digitaaliset gradut voivat olla luettavissa avoimesti verkossa tai rajoitetusti kirjaston opinnäytekioskeilla.Endast sammandrag. Inbundna avhandlingar kan sökas i Helka-databasen (http://www.helsinki.fi/helka). Elektroniska kopior av avhandlingar finns antingen öppet på nätet eller endast tillgängliga i bibliotekets avhandlingsterminaler.Tutkielmassa tarkastellaan avoliitossa eläviä 65 vuotta täyttäneitä suomalaisia rekisteriaineistojen valossa. Avoliitossa eläminen on iäkkäiden keskuudessa yleistynyt nopeasti niin Suomessa kuin muissakin teollisuusmaissa. Iäkkäiden avoliittojen luonteesta sekä avoliitossa elävien ja muun vanhusväestön välisistä sosioekonomisista ja terveydellisistä eroista tiedetään kuitenkin hyvin vähän. Tutkielmassa selvitetään, miten avoliitossa elävien osuus 65 vuotta täyttäneistä suomalaisista on muuttunut vuosina 1992–2003, millaisia ovat avoliitossa elävien ikääntyneiden sosiodemografiset ja -ekonomiset ominaisuudet ja miten ikääntyneiden avoliitot purkautuvat erilleen muuton, laitoshoitoon joutumisen ja kuoleman kautta viiden vuoden seurannassa. Avoliitossa eläviä verrataan sekä yksin että aviopuolison kanssa eläviin ikävakioitujen prosenttiosuuksien sekä binäärisen ja multinomiaalisen logistisen regressioanalyysin avulla käyttäen Tilastokeskuksen muodostamia laajoja rekisteriaineistoja. Tutkielma osoittaa, että ikääntyneiden avoliitot ovat harvinaisia. 2000-luvun alussa alle kolme prosenttia 65 vuotta täyttäneistä suomalaisista asui avopuolison kanssa. Etenkin eronneiden ja leskien keskuudessa avoliitossa eläminen on kuitenkin yleistynyt nopeasti. Iäkkäiden avoliitot ovatkin pääosin avioeron tai leskeytymisen jälkeen solmittuja uusia liittoja. Avoliitossa elävät iäkkäät ovat useilta sosioekonomisilta ominaisuuksiltaan heikommassa asemassa kuin avioliitossa elävät ja naisilla myös huonommassa asemassa kuin yksinelävät. Matala sosioekonominen asema miehillä ja matala koulutus naisilla sekä vuokralla asuminen sekä miehillä että naisilla ovat yhteydessä avoliittoisuuteen iäkkäiden keskuudessa. Avoliitossa elävät naiset ovat kuitenkin avioliitossa eläviä parempituloisia. Iäkkäiden avoliitot ovat avioliittoja epävakaampia ja purkautuvat avioliittoja useammin eron, laitoshoitoon joutumisen ja kuoleman kautta. Etenkin erilleen muuttaminen on avoliitossa huomattavasti yleisempää kuin avioliitossa. Avo- ja avioliitossa elävien väliset erot laitoshoitoon joutumisessa ja kuolleisuudessa selittyvät vain osittain sosioekonomisilla eroilla, lähinnä eroilla asunnon omistamisessa. Erilleen muuttamisen riski ei riipu lainkaan sosioekonomisista tekijöistä. Yksin eläviin verrattuna avoliitossa elävillä miehillä on pienempi riski joutua laitoshoitoon. Kuolleisuuden suhteen avoliitossa elävät miehet eivät poikkea yksin elävistä. Naisilla avoliitossa elävien riski joutua laitoshoitoon ei poikkea yksin elävien riskistä, kuolleisuus on avoliitossa elävillä huomattavasti suurempi. Tulosten perusteella avopuolisot eivät tarjoa iäkkäille aviopuolisoiden lailla hoivaa ja tukea. Avoliitto näyttäisi iäkkäillä olevan pikemminkin heikkoa sitoutumista edellyttävä seurustelutyyppinen asumismuoto kuin avioliiton kaltainen pitkä ja vakiintunut liitto. Avoliittojen yleistyessä vanhemman väestön keskuudessa, tulee yhä suurempi osuus iäkkäistä elämään epävakaissa, vähän suojaa ja hoivaa tarjoavissa liitoissa. Tämä saattaa vaikuttaa yhteiskunnassa tarvittavien virallisten hoivapalveluiden määrään. Iäkkäiden avoliitot saattavat kuitenkin yleistyessään normalisoitua ja muuttua luonteeltaan enemmän avioliiton kaltaisiksi

Health-related selection into employment among the unemployed

Background Successful transitions from unemployment to employment are an important concern, yet little is known about health-related selection into employment. We assessed the association of various physical and psychiatric conditions with finding employment, and employment stability. Methods Using total population register data, we followed Finnish residents aged 30–60 with an unemployment spell during 2009–2018 (n = 814,085) for two years from the onset of unemployment. We predicted any, stable, and unstable employment by health status using Cox proportional hazards models. The data on specialized health care and prescription reimbursement were used to identify any alcohol-related conditions and poisonings, psychiatric conditions and self-harm, injuries, and physical conditions. We further separated physical conditions into cancer, diabetes, heart disease, and neurological conditions, and psychiatric conditions into depression, anxiety disorders and substance use disorders. Results The likelihood of any employment was lower among those who had any of the assessed health conditions. It was lowest among those with alcohol-related or psychiatric conditions with an age-adjusted hazard ratio of 0.45 (95% confidence interval 0.44, 0.46) among men and 0.39 (0.38, 0.41) among women for alcohol-related and 0.64 (0.63, 0.65) and 0.66 (0.65, 0.67) for psychiatric conditions, respectively. These results were not driven by differences in socioeconomic characteristics or comorbidities. All the included conditions were detrimental to both stable and unstable employment, however alcohol-related and psychiatric conditions were more harmful for stable than for unstable employment. Conclusions The prospects of the unemployed finding employment are reduced by poor health, particularly alcohol-related and psychiatric conditions. These two conditions may also lead to unstable career trajectories. The selection process contributes to the health differentials between employed and unemployed people. Unemployed people with health problems may therefore need additional support to improve their chances of employment.Peer reviewe

Parental Unemployment and Offspring Psychotropic Medication Purchases : A Longitudinal Fixed-Effects Analysis of 138,644 Adolescents

Parental unemployment is associated with worse adolescent mental health, but prior evidence has primarily been based on cross-sectional studies subject to reverse causality and confounding. We assessed the association between parental unemployment and changes in adolescent psychotropic medication purchases, with longitudinal individual-level fixed-effects models that controlled for time-invariant confounding. We used data from a large, register-based panel of Finnish adolescents aged 13–20 years in 1987–2012 (n = 138,644) that included annual measurements of mothers’ and fathers’ employment and offspring psychotropic medication purchases. We assessed changes in the probability of adolescent psychotropic medication purchases in the years before, during, and after the first episode of parental unemployment. There was no association between mother’s unemployment and offspring psychotropic purchases in the fixed-effects models, suggesting this association is largely driven by unmeasured confounding and selection. By contrast, father’s unemployment led to a significant 15\20\% increase in the probability of purchasing psychotropic medication among adolescents even after extensive controls for observed and unobserved confounding. This change takes at least 1 year to emerge, but it is long-lasting; thus, policies are needed that mitigate the harm of father’s unemployment on offspring’s mental well-being.Parental unemployment is associated with worse adolescent mental health, but prior evidence has primarily been based on cross-sectional studies subject to reverse causality and confounding. We assessed the association between parental unemployment and changes in adolescent psychotropic medication purchases, with longitudinal individual-level fixed-effects models that controlled for time-invariant confounding. We used data from a large, register-based panel of Finnish adolescents aged 13–20 years in 1987–2012 (n = 138,644) that included annual measurements of mothers’ and fathers’ employment and offspring psychotropic medication purchases. We assessed changes in the probability of adolescent psychotropic medication purchases in the years before, during, and after the first episode of parental unemployment. There was no association between mother’s unemployment and offspring psychotropic purchases in the fixed-effects models, suggesting this association is largely driven by unmeasured confounding and selection. By contrast, father’s unemployment led to a significant 15%–20% increase in the probability of purchasing psychotropic medication among adolescents even after extensive controls for observed and unobserved confounding. This change takes at least 1 year to emerge, but it is long-lasting; thus, policies are needed that mitigate the harm of father’s unemployment on offspring’s mental well-being.Peer reviewe

Time patterns of external and alcohol-related mortality after marital and non-marital separation : the contribution of psychiatric morbidity

Background External and alcohol-related mortality is elevated postseparation, but the role of poor mental health in explaining this excess is unclear. We assess postseparation excess mortality by union type and over time since separation and examine how psychiatric morbidity present already before separation, during the separation process and after separation attenuates this excess. Methods Using individual-level register data from 1995 to 2012, we followed 311 751 Finns in long-term unions. Psychiatric morbidity was identified from dates of prescription medication purchases and hospital admissions, separations from dates of moving out of joint households and mortality from the Death Register. Cox regression was used to analyse postseparation mortality controlling for psychiatric morbidity before, during and after separation. Results External and alcohol-related excess mortality is most pronounced immediately after separation, particularly among men, and is much larger following marital than non-marital separation. After sociodemographic factors are adjusted for, further adjustment for psychiatric morbidity attenuates the excess by about 25%. Psychiatric morbidity poorly explains alcohol-related postseparation excess mortality, but for suicide mortality, adjustment for psychiatric morbidity reduces the excess by about 40% among men and 50% among women. Among women, this is largely due to psychiatric morbidity present already before separation, whereas among men the attenuation is also due to psychiatric morbidity during the separation process and after it. Conclusion Separation may exacerbate the problems of people already in poor mental health, and relationship dynamics should thus be considered during treatment. Particularly among men separation is a risk factor for suicide even without pre-existing mental health problems.Peer reviewe

Early Adolescent Health Problems, School Performance, and Upper Secondary Educational Pathways : A Counterfactual-Based Mediation Analysis

Peer reviewe

Trends in life expectancy in residential long-term care by sociodemographic position in 1999–2018: a multistate life table study of Finnish older adults

Objectives: Residential long-term care (LTC) use has declined in many countries over the past years. This study quantifies how changing rates of entry, exit, and mortality have contributed to trends in life expectancy in LTC (i.e., average time spent in LTC after age 65) across sociodemographic groups. Methods: We analyzed population-register data of all Finns aged ≥65 during 1999–2018 (n = 2,016,987) with dates of LTC and death and sociodemographic characteristics. We estimated transition rates between home, LTC, and death using Poisson generalized additive models, and calculated multistate life tables across 1999–2003, 2004–2008, 2009–2013, and 2014–2018. Results: Between 1999–2003 and 2004–2008, life expectancy in LTC increased from 0.75 (95% CI: 0.74–0.76) to 0.89 (95% CI: 0.88–0.90) years among men and from 1.61 (95% CI: 1.59–1.62) to 1.83 (95% CI: 1.81–1.85) years among women, mainly due to declining exit rates from LTC. Thereafter, life expectancy in LTC decreased, reaching 0.80 (95% CI: 0.79–0.81) and 1.51 (95% CI: 1.50–1.53) years among men and women, respectively, in 2014–2018. Especially among women and nonmarried men, the decline was largely due to increasing death rates in LTC. Admission rates declined throughout the study period, which offset the increase in life expectancy in LTC attributable to declining mortality in the community. Marital status differences in life expectancy in LTC narrowed over time. Discussion: Recent declines in LTC use were driven by postponed LTC admission closer to death. The results suggest that across sociodemographic strata older adults enter LTC in even worse health and spend a shorter time in care than before

Evaluating the Role of Parental Education and Adolescent Health Problems in Educational Attainment

This article reconsiders the role of social origin in health selection by examining whether parental education moderates the association between early health and educational attainment and whether health problems mediate the intergenerational transmission of education. We used longitudinal register data on Finns born in 1986–1991 (n = 352,899). We measured the completion of secondary and tertiary education until age 27 and used data on hospital care and medication reimbursements to assess chronic somatic conditions, frequent infections, and mental disorders at ages 10–16. We employed linear probability models to estimate the associations between different types of health problems and educational outcomes and to examine moderation by parental education, both overall in the population and comparing siblings with and without health problems. Finally, we performed a mediation analysis with g-computation to simulate whether a hypothetical eradication of health problems would weaken the association between parental and offspring education. All types of health problems reduced the likelihood of secondary education, but mental disorders were associated with the largest reductions. Among those with secondary education, there was further evidence of selection to tertiary education. High parental education buffered against the negative impact of mental disorders on completing secondary education but exacerbated it in the case of tertiary education. The simulated eradication of health problems slightly reduced disparities by parental education in secondary education (up to 10%) but increased disparities in tertiary education (up to 2%). Adolescent health problems and parental education are strong but chiefly independent predictors of educational attainment.Peer reviewe